How Medicine is Practiced Today
November 7, 2021 (2,413 words)
The actor Stanley Tucci has appeared in over 70 films, and he always manages to be an authentic, relatable presence, even as a villain. The other night he was interviewed on NPR about a new book he has out, which describes a deep and abiding love of freshly prepared food inherited from his parents, and how his sense of taste was adversely affected for a time by his recent bout with oral cancer.
Mr. Tucci praised the medical care he received during his initial diagnosis and extensive treatment, and told the listening audience how one of his cancer doctors has actually gone on to become a close family friend.
Many older folks share his sentiments. They enjoy a close bond with their primary care physician, and with other medical specialists their deteriorating condition prompts them to consult.
I, however, am not one of those people. Without ever having held any sort of grudge against the medical profession, mind you, I’ve managed to live a doctor-free existence for most of my life.
That all changed a few years ago when a series of nagging ailments began to visit themselves upon me. After being fit as a fiddle for so long I found myself in various and sundry waiting rooms, filling out the same form over and over again. Being seen for a few minutes by two and sometimes three assistants, who often ask the very same questions you just answered on that multi-page form you are forced to complete upon arrival.
Then the doctor (my primary care guy, an internist, a couple of different urologists, an optometrist) pops in for a few moments, usually with his/her nose firmly planted in his/her laptop, where all my vitals are conveniently stored.
Just for the record, I’ve also found my way to the emergency room of my local hospital a few times during this stretch, and had occasion to visit the neighborhood Urgent Care walk-in-with-no-appointment place more than once. I’ve also had a series of blood tests taken, and more CAT scans and MRIs than I can keep track of.
Most of my little afflictions have turned out to be false alarms. Nothing to get overly excited about, just a natural part of the aging process. Unpleasant, but unavoidable. Except for the Type II diabetes I have been diagnosed with. After fainting and falling to the floor in a restaurant, the EMTs who came to my rescue pricked me and said my A1c level was 12% (instead of 7%), and told me I needed to get this checked out.
I went to see my primary care doc – a relatively young man appearing to be in his early-forties – who assured me this condition did not require the services of a specialist. He told me straight away to change my diet and avoid starchy carbs, and stressed the need for regular exercise. He also proscribed a common diabetes medication called Metformin, a pill I was to take twice daily.
I left his office determined to turn over a new leaf. I immediately gave up what used to be my favorite foods: potatoes, pasta, pizza, and bread. I started swimming laps at the Y. I lost a few pounds along the way, and had to buy some new clothes to fit the now leaner version of me.
And I took my Metformin religiously, twice a day as proscribed. When I went back for a follow-up visit, new blood test in hand showing my A1c was now at 7.1%, I expected a round of applause. Instead, the young physician’s assistant peered at her laptop, only to announce my current A1c was higher than it should be. Completely oblivious to the dramatic progress I had made. Same thing with my primary care doc, once the assistant left and he appeared in the little exam room.
My next few check-ups came and went, during which I kept giving these two the benefit of the doubt, so to speak. They were the experts and I should follow their advice. Even if their bedside manner left a little to be desired.
Then I had a casual encounter with someone who told me that of course Metformin is not really good for you. Like all medications, this civilian explained, it was intended to curb one problem, but it usually interfered with another bodily function in the process. The details were admittedly sketchy, but the overall theme struck a chord, and reminded me why I had steered clear of doctors and prescription medicine over the course of the last five decades.
Once I stopped eating starchy carbs and started swimming laps 3-4-5 times a week, I began to regain my equilibrium. The dizzy spells were a thing of the past, and I was feeling pretty good once again. After a year or so I decided on my own, without consulting a physician, to stop taking the Metformin.
In advance of a regularly scheduled doctor’s visit this past June I had another blood test done, and it revealed my current A1c level was now at 7.4%. Still manageable, in my opinion. No need to go back on Metformin, as far as I was concerned. When I shared what I thought was the good news, my primary care doc had a fit. How dare I stop taking medication he had proscribed. There was no discussion, no interest in how I was feeling or what diet and exercise regime I was following. From behind my mandatory COVID-19 face mask I calmly suggested another blood test in a few months, to make sure things aren’t trending in the wrong direction. “Not unless you are prepared to go back on the Metformin,” he said with undisguised anger, before getting up and kind of storming out of the exam room.
One could chalk up this doctor’s brusque attitude to any number of things. It was the end of a long day, and perhaps his patience was frayed. Long day or not, over the course of my previous visits a petulant streak seemed to be lurking just below the surface with this guy. Then again, I could be reading things all wrong. He could very well be a perfectly competent physician who just happens to be a little lacking in the empathy department.
And let’s not forget the frustration factor. Doctors keep telling us we need to change our diet and start to exercise, but hardly anybody ever does. Most of us go right on eating the foods we love, though they are demonstrably bad for us, and we almost never get any exercise. This has got to frustrate the living daylights out of any conscientious physician. Almost by default, they have no choice but to push a menu of prescription medications to treat what ails us.
Another mitigating circumstance contributing to what can be an occasional bout of brusqueness on the part of our medical professionals is the way every practice has decided to “scale.” This business model involves seeing as many patients as possible. More patients seen means fewer time spent with each patient. This is an unfortunate trend that puts an unreasonable demand on the individual doctor, and results in a less satisfying experience for the patient.
One can only learn so much from a cursory glance at a series of standard medical history questions that often don’t lend themselves to straightforward yes-or-no answers. It’s hard to know your patient when you only spend a few minutes with them. And when a good part of that time is spent looking at your laptop.
This is one of my gripes with how medicine is practiced today, minor malady division. The data our doctors have loaded onto their laptops is fine, as far as it goes. But it can’t tell the whole story. In order to truly “do no harm” you need to pay some attention to the actual human being sitting in front of you.
As a follow-up to that contentious doctor’s visit of last June, I just had another blood test taken the other day, and my A1c level is holding steady at 7.4%. That’s with me being off the Metformin for over nine months. When it comes to treating my version of Type II diabetes, it would appear the ever-popular “diet and exercise” thing is a winning formula.
This is not meant as a grand indictment of Metformin, per se, or of the physician who proscribed it. The medication is there if you need it. But if you don’t need it, why take it? I only wish my primary care doctor noticed how seriously I heeded his advice on the diet and exercise portion of his initial proscription. Apparently in his eyes I was going to be on Metformin for the rest of my life. Regardless of what I choose to eat, and regardless of what exercise regime I may adopt.
That doctors seem to automatically and reflexively proscribe medication is another gripe I have with how medicine is practiced today. Though I admit they may be spurred in that direction by demanding patients who come in looking for a magic pill that will make everything better.
This medication-first approach stems from what strikes me as a denial of the obvious on the part of doctors and patients alike. It’s as if we have all forgotten the human body is not built to last. Sure, it’s good to try and keep things running as smoothly as possible, for as long as one can. But we are all falling apart, some more slowly than others, and we’re all going to die at some point in the not-too-distant future.
Granted my sample size is limited, and my evidence is purely anecdotal. But I am walking into these doctors’ offices as a relatively old man now. My best days are behind me. There are going to be aches and pains. My eyesight is failing and I don’t hear so good. I get up in the middle of the night to use the bathroom. I have a slight tremor in my right hand, the one I write with, that appears then disappears then reappears. There are just certain things that come with the territory, you know what I mean?
It feels like these youngish doctors are approaching me as if anything less than triathlon-level physical condition is cause for alarm, and requires “treatment.” Instead of a simple annual check-up, they insist on seeing me three times a year to monitor my condition, as if I’m on the verge of imminent collapse.
But again, this may not be all their fault. Too many of us are showing up at our doctors’ offices with symptoms that are either a natural part of the aging process, or the direct result of our own negligence, and saying “fix me.” In a world where we have been instructed over and over again to demand the best and have it our way, we are unwilling to accept the inevitable ravages of time. And simultaneously with that unrealistic expectation, we aren’t taking very good care of ourselves these days, either.
As has been duly noted in any number of venues, the conveniences that have become commonplace since, let’s say the 1950s, have resulted in a more sedentary lifestyle for most of us. And have inclined many of us to consume a much higher percentage of fast, processed food. These foods taste great but often lack any nutritional value. We end up eating more of them than we should, because our bodies are left craving a basic level of nutrition.
Lousy eating habits combined with little-to-no physical activity results in negative health outcomes, as they say. This forces doctors to deal with the by-product of our poor choices. I don’t envy them.
The written report from my latest blood test states: “For someone with known diabetes, a value of 7% indicates that their diabetes is well controlled and a value greater than or equal to 7% indicates suboptimal control. A1c targets should be individualized based on duration of diabetes, age, comorbid conditions, and other considerations.”
I would like to find a primary care doctor who is willing to “individualize” my A1c “target” by discussing my circumstances in some detail, rather than relying on a chart that reads “A1c should be 7% or lower.” I’m not opposed to going back on Metformin if my condition worsens. But in my case an A1c reading of 7.4% may be okay, considering how I am feeling otherwise. The bottom line is I don’t want to be on a prescription medication if I don’t really need to be. Is that so wrong?
A lack of personalized attention has infected many of the service industries we come into contact with – not just medicine. As a general rule, the bigness of an enterprise enhances its profit potential, but usually undercuts the quality of service being provided.
Then again, in the interest of giving doctors their due, our medical system does a pretty good job with the big stuff: trauma, transplants, cancer, etc. Just think of all those in-depth heart-to-heart consultations you see doctors and patients engage in on your favorite dramatic series.
The annoying tests we are routinely sent out to have done are often the only way to screen for these bigger problems. I’m prepared to submit to my fair share of MRIs and CAT scans every so often. But why not make getting those tests approved and paid for less of a bureaucratic labyrinth?
The way things are now feels like a giant game of bait-and-switch. No doctor or physician’s assistant or front desk personnel ever tells you what anything will cost, because they’re trying to wrangle as much money as possible out of the insurance company. And you’ll never get a straight answer on costs out of the insurance company in advance of a procedure. The patient is a pawn in a complicated chess match being played far above their head.
I’m not one to sit back and pine for the good old days. But neither do I accept the premise that everything we are doing today represents a step forward from the way it used to be done. It’d nice to hear the actor Stanley Tucci is smitten with his cancer doctors. I’d settle for a primary care doc who would notice what a bang-up job I’m doing of dealing with my Type II diabetes through diet and exercise, without having to resort to prescription medication.
Robert J. Cavanaugh, Jr
November 7, 2021